Sunday, October 3, 2010

Electronic Medical Records (EMR) promises to be the holy grail of modern medicine.It aims to deliver us from the Smith Corona era into the digital age.I’m a gastroenterologist who has already been practicing digitally for two decades.I guess I am way ahead of my time

Is EMR progress?Consider these two hypotheticalpatient assessments.The assessment is a critical section of the medical record where the physician shares his thinking on the patient’s condition.The assessment answers the question, “What do you think is going on here and why?”

The Old Fashioned, Archaic, Fossilized and Sclerotic Assessment

The quality and timing of the patient’s abdominal pain is strongly suggestive of mesenteric ischemia (lack of blood supply to the guts), as the pain consistently develops 45 minutes after meals.The patient has numerous risk factors for this condition.Peptic ulcer disease is unlikely as the patient has been on an effective anti-ulcer medicine for months.The frequency of the pain is not typical for gallbladder disease or pancreatitis…

The New & Improved EMR Assessment

Abdominal pain, unspecified

Our office manager admonished me earlier this week because I was free typing the medical history section, rather than use‘point and click’ ( P & C).Apparently, if I free type and forego the template entirely, it stymies the coding process.(For non-physicians, coding = getting paid.)While EMR vendors are convinced that medical histories can be recorded using P & C technique, I’m a deep skeptic.The medical history is a narrative, a record of a fluid, and sometimes meandering dialogue between patients and physicians.The history probes in all directions.It wanders.It creates new passageways. The patient’s response to a question often opens up a new avenue of inquiry, a function that cannot be reproduced on a rigid template.

Imagine how our personal conversations would be if we communicated using a P &C template.

Steve:“Jim, it’s great seeing you?It’s been a while.How’s it going?”

Jim:“Samantha’s having a rough time with chemo and I was just laid off.”

Steve: “Fantastic!Are you free to golf this weekend?“

I do believe that EMR systems in time will fulfill their early promises.They will incorporate excellent voice recognition software.The myriad of EMR systems will be integrated so that a recent emergency room visit will automatically be transmitted to my patient’s EMR record.Patients will have their medical histories, EKGs, medical images, etc., recorded on flash drives, which will load into any EMR system.When this occurs, it will no longer be possible to be an EMR non-believer.

But, some of today’s EMR whistles are whistling in the dark.For example, we physicians all nodded like bobble-head dolls when we were told that we could have access to patient’s records at home after hours.This meant that when we received weekend phone calls from our partners’ patients, whom we did not know, we could access their medical record and give better medical advice.Of course, this makes sense, but is it really true?

First, it’s tough for cyber neophytes like me to boot up the laptop when a patient calls while I am behind the wheel.Secondly, I have been handling patient calls at all hours for 20 years, and I have somehow managed to handle the issues with few catastrophic consequences.Indeed, all practicing physicians have developed this important skill set of triaging patients by phone.Our role here is not to make a diagnosis; it is to decide if a patient needs an emergency room visit or can be seen electively in the office.I’m not suggesting that reviewing record is not useful, only that the benefit of instant access may be exaggerated in certain circumstances.

I’m sure that EMR 2.0 and its descendants will ultimately deliver. So far, it hasn’t surpassed ink on paper in my practice, although it's only been a few weeks. So far, as expected, EMR has not brought me closer to my patients. To paraphrase a past U.S. president, it's a divider, not a uniter.

I realize that there are some physician EMR users who worship the new technology. There are indisputable advantages that they can and will bring to medical care. Some EMR systems may be better than others. However, this has not a downhill sleigh ride for many doctors and patients, at least not yet. Interestingly, the majority of physicans are still content to use paper charts. In the near term, they will transition to EMR, not so much because of a Damascus Road conversion, but because payers will require it.

I admit that with each passing week, it is getting smoother for us. But, it has taken an enormous investment of T & T (training & tweaking) time, which is ongoing. And, we haven't yet incorporated our endoscopy practice into the system. At the start, it may take longer to document a colonoscopy than to do one.

For me, blogging is the EMR antidote.It’s open terrain.There are no moats or fences.It’s unpredictable and spontaneous.It’s emotional and creative.It has a point, but not a single click.

19 comments:

Anonymous
said...

Developers of EMR software need to have a full understanding of the process, including the purpose of things such as the H&P, HPI, etc. It sounds like you have 2 processes that are trying to be addressed with 1. Coding draws information from the H&P, but it's a different animal. For an EMR to be successful, the developers must realize these differences.

Obama's claim that EMR would free up $20 billion was such a howler that even some of his supporters took him to task for it. It also took his administration about a year to define just who would have their EMR purchases covered by the stimulus and who wouldn't. I still don't trust him, and will just have to get used to the penalty I'll incur for not buckling under.

While I am not a medical professional and some of the items in this post were difficult for me to understand, I know that in the recent years whenever I go to a doctor, they have a number of my medical records from other offices electronically transferred. It makes things much better and easier for patients, doesn't it?

As long as we are treating human beings, medicine will continue to be clinical judgements made by physicians. Useful medical records need to reflect that fact, a fact often lost on point and click and template EMR that rely on ICD-9 coding. EMR Clinic notes tend to be long, verbose and vague. Useful assesments are those similar to the "sclerotic" assessment above- I know what Dr. Kirsch is thinking about. We have not figured out how to best use EMR for clinical practice, but the government has unfortunately already defined that for us with their "clinically meaningful use" criteria. Those criteria are not really designed to let physicians and nurses practice their best medicine, but rather to keep tabs on "quality" and billing. If EMR as it now exists, was really such a great idea, you would not need incentives. No incentives were needed for physicians to adopt cell phones or electronic scheduling. Simply put, the present EMR's suck, and the promise of "instant access" to patient information (labs, etc) is poor at best.

Though I like EMR in general, you are right on about a problem in the lack of prose. Tell your office manager to f off. Going to a point and click assessment is no longer being a good doctor, and we're not willing to do that.

I'm a "lurker" on your site, and a frequent reader of the HealthCare Renewal site. Though you might find this article of interest as you go forward with your adventure in electronic technology. http://hcrenewal.blogspot.com/2010/10/21st-century-emr-experiments-screwing.html#links

Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, Wisconsin, USA.

Abstract

Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. [Not discussed are the origins and maintenance vectors of those fallacies, a topic for significant research itself - ed.] We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.

I have a brief post on it at http://hcrenewal.blogspot.com/2010/10/jamia-health-information-technology.html

As a denial management specialist to hospitals to argue insurance denials, the EMR dilutes the recipe for accurate documentation - poignant, specific and detailed documentation that supports the status of the patient and substantiates why that patient is in the hospital. All too often professionals complete the pre-formulated checklists and one cannot tell Patient A from Patient B. It is not a substitute for narrative.

Hospitals and professionals who engage in electronic charting need to also become environmentally conscious - the mounds of paper that are being wasted are incredulous. There seem to be a few companies that minimize wasting and also have a layout that is conducive to professional thought processes(i.i. tables of lab results rather than one day of lab results on each page). The EMR companies seem to be dictating the standards, while it should be the professsionals to minimize error etc.

"Patients will have their medical histories, EKGs, medical images, etc., recorded on flash drives, which will load into any EMR system. When this occurs, it will no longer be possible to be an EMR non-believer."

Michael, that's what the MedKaz™ is all about. Would love to have you participate in our forthcoming pilot study. At the very least, I'd like to talk with you. You can reach me at 802 484-0249, or I'll call you.

As a person who is about to add an EMR product to his ultrasound supplies business, this article was very informative. It's allowing me to see the constraints through your eyes. In fact, the backbone example that you mentioned (how an ER visit could be sent to your EMR) is something a friend and have discussed and currently working on it. I will definitely feed your blog posts into my twitter account b/c they are very informative.

This is very interesting information. We have been doing research on EMR to see if it is a good fit for our company. So far what we've read has been so helpful. Thanks so much for sharing your article, it was very helpful for us as well.

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About Me

I am a full time practicing physician and writer. I write about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When I'm not writing, I'm performing colonoscopies.